What you need to know before changing your medical aid benefit option

It is that time of year again when everyone takes a closer look at their money in anticipation of the upcoming holiday season. At the same time, many start thinking about the new year and what changes they need to make once the holidays are over. As a medical aid member, you may have already received your annual increase announcement and may be considering switching plans to get better value for your money. But are you fully aware of the rules that may apply before you make the switch? Medshield offers you some guidelines to help you make your decision.

How to decide on an option?

Understanding the benefits of the option you are considering – including prescribed minimum benefits (PMBs), chronic medication and the medicine formulary, day-to-day, dental, optical benefits, and hospitalisation – is a task best undertaken with the advice and guidance of your financial advisor.

Changing to a lower benefit option will result in lesser benefits entitlement, and there may be a significant impact on how your chronic medication will be covered as opposed to the formularies used by your previous option. It could lead to more out-of-pocket expenses due to certain medicine/s not being covered on your new option. Certain benefit limits on specific options only cover PMBs, meaning that non-PMB conditions and procedures will not be covered.

Is the change affordable for you?

Make sure you are making the switch that will benefit you in the long term. If you simply want to pay less, you might compromise your cover only to realise your mistake at the claim stage. So ensure you have enough cover and understand how the potential benefit option works.

What about network providers?

It is essential to consider the choice of network providers, as specific benefit options allow you to choose freely, while other options are network restricted. Medshield negotiates preferred rates with healthcare providers to ensure that your benefits last throughout the year and, therefore, the existence of healthcare provider networks. But healthcare provider networks may differ from option to option.

Most people on medical aid already have their preferred doctor and hospital, and switching benefit options – especially an option with a lower premium – might mean losing access to your preferred healthcare provider. Please ensure that you have read and understood the benefits and networks of your selected option. Discuss with your financial advisor to confirm that your choice best suits your medical and financial needs before selecting.

Are you changing from a hospital plan to a plan with out-of-hospital benefits?

Sometimes members need to change from a hospital plan that only covers hospital stay to more day-to-day or out-of-hospital coverage for several reasons. In this instance, review the healthcare provider networks and the cover available on the out-of-hospital benefits, since the Scheme Rules governing that plan will always be applied.

Are there any waiting periods?

There are two types of waiting periods as authorised by the Medical Schemes Act: the general waiting period of up to three months and a condition-specific waiting period (up to 12 months). These could apply if you move from one medical aid to another, have never been a medical aid member, or have not been on medical aid for at least 90 days.

If you are already a member and move between options, there is no waiting period unless you are serving a waiting period on your current option. The remaining time of the waiting period will then just be transferred to the new benefit option, but no new waiting periods will be applied.

The waiting period protects other members of the Scheme by ensuring that individuals cannot make large claims shortly after joining and then cancel their membership after the claim has been settled. As a new member, you continue to pay your total premium during the waiting period.

When to make the switch?

Members are free to change between benefit options or plans once a year during November and December, and the change will be effected on 1 January 2023. Should you choose not to change your benefit option, you will automatically remain on your current option for 2023.

It is also the best time to switch if you want to move from your current medical aid to Medshield. All your specific details and medical history will be recorded for ease of reference when you begin your new journey with us. We welcome all new members, individual or corporate and offer a wide range of benefit options tailored to specific needs.